Table 2 Articles included in the scoping review

Back-Brito [36] Brazil

To evaluate fungal microflora in the oral cavity

Matched case–control

N = 59

AN, BN

The identification of uncultured microflora species first reported in this study was also observed in dental biofilm from the ED group

Boillot [37]

France

To determine whether generalized reduced periodontium and dental erosion in women with EDs are associated with systemic biological parameters

Secondary analysis of the PERIOED case–control study

N = 45 Female

AN, BN

Serum ferritin levels together with age may be helpful in screening patients with ED for adequate referral to a dentist

Burgard [19]

USA

To better understand how dental practitioners identify, counsel, and refer patients with EDs

Survey

N = 123

N/A

Approximately 50% of respondents reported evaluating a patient with an ED in the past year and most spoke to the patient or a parent. Some respondents do not raise concerns due to ambiguity of dental findings or not knowing what to say. Less than 1/3 referred patients to additional care, and those who did, referred almost exclusively to primary care

Conviser [56]

USA

To understand oral health behaviors after purging and patient perspectives on barriers to patient-initiated discussion of EDs with OHPs

Cross-sectional survey

N = 201

BN

Participants had high levels of concern about their oral health and a high incidence of oral health problems, but less than one third considered their OHPs to be the most helpful source of oral health information

De Moor [38] Belgium

To present a case of a female patient with a history of AN, followed by BN that resulted in dental destruction over a 5-year period

Case study

N = 1

AN, BN

Early erosions were particularly limited to the lingual surfaces of the maxillary anterior teeth and occlusal surfaces of the maxillary premolars and mandibular posterior teeth. Resin restorations have been used to restore teeth with erosion and those demonstrating dentine hypersensitivity

DeBate [27]

USA

To determine the knowledge among dentists and dental hygienists concerning the oral and physical manifestations of EDs

Randomized cross-sectional study

N = 945

N/A

Most respondents had low knowledge of clinical findings associated with EDs, with hygienists more likely to identify oral manifestations. There was generally low knowledge of physical manifestations of EDs

DeBate [26]

USA

To explore beliefs, attitudes, and experiences of general dentists regarding ED-specific secondary prevention behaviors

90-min focus groups

N = 21

N/A

Curriculum development, policies, and practices are places for intervention to support and sustain secondary preventive clinical behaviors among dentists

DeBate [22]

USA

To explore readiness and capacity for integration of oral health and mental health services

Cross-sectional survey

N = 378

N/A

Only 18% of the sample reported referring patients to clinical eating disorder care. It is important to improve capacity for secondary prevention and self-efficacy

DeBate [28]

USA

To assess sex differences among dentists pertaining to current behaviors and behavioral beliefs about EDs

Cross-sectional survey

N = 350

N/A

Respondents had an overall low level of secondary ED prevention practices. Dissonance was observed between dentists about reported high levels of perceived benefits of prevention practices and self-efficacy and the modest number of dentists currently engaged in secondary prevention practices. More female dentists reported engagement in prevention practices than their male counterparts

DeBate [25]

USA

To assess the breadth and depth of ED specific comprehensive and primary care instruction in dental and dental hygiene curricula

Cross-sectional survey

N = 114

N/A

The findings indicate an increased inclusion of ED training in programs from a previous study. More dental hygiene programs include ED education than dental programs. There is a significant lack of training in communication with patients exhibiting signs of EDs

DeBate [23]

USA

To develop and evaluate a program to improve secondary prevention of EDs in oral health providers

Two phase study:

Phase 1: focus groups, N = 41

Phase 2: pilot evaluation, N = 64

N/A

There was a statistically significant change from pre intervention to post intervention across variables. Participants found training useful, provided more information than generally available, and was appropriately tailored

DeBate [21]

USA

To develop and evaluate a framework aimed at oral healthcare providers to engage in active secondary prevention of EDs

Group randomized controlled trial

N = 18

N/A

There was significant improvement from pre-intervention to post-intervention in the intervention group compared to the control group on knowledge of EDs and oral findings, skills-based knowledge and self-efficacy

DeBate [24]

USA

To test whether an interactive, web-based training program is more effective than an existing, latest e-learning program at improving oral health students’ knowledge, motivation, and self-efficacy to address signs of disordered eating behaviors with patients

Group randomized controlled trial

N = 18 classes, 317 students

N/A

Post-test differences between groups showed greater improvement among intervention participants in three domains compared to the alternative program. The findings suggest that interactive training programs may be better than e-learning

DeBate [20]

USA

To use IM to develop a theory- and evidence- based intervention to increase the capacity of oral health providers to engage in secondary prevention of EDs

Prospective group-randomized controlled trial

N = 27

N/A

The systematic IM process resulted in an innovative theory and evidence-based training curriculum that highlighted the importance of oral-systemic health and associated clinical behaviors that can positively impact the overall health of persons with ED behaviors

DiGioacchino [29] USA

To build a framework for the development of effective programming to increase the proportion of dental practitioners involved in secondary and tertiary prevention and case management

Pen and paper survey

N = 45

N/A

The findings indicate that dentists and hygienists were not aware of complications/manifestations of EDs. There was a lack motivation to take action, with identified barriers to action of difficulty speaking to patients about concerns of ED and lack self-efficacy in corresponding with primary care providers or referral processes

Dynesen [39] Denmark

To study if BN has an impact on salivary gland function, if salivary gland function relates to dental erosion in persons with BN, and if dental erosion in BN is related to behavior regarding diet, purging, and duration of the ED

Case–control, questionnaire and dental exam

N = 40

BN

The BN persons had impaired unstimulated whole saliva (UWS), mainly owing to medication; increased feeling of oral dryness; and more dental erosion. Dental erosion was related to the duration of ED, whereas no effect of vomiting frequency or intake of acidic drinks on reduced UWS was observed

Dynesen [57] Denmark

To uncover knowledge, experience, and attitudes of oral health and oral health behavior among persons with EDs

Cross-sectional, electronic questionnaire

N = 260

AN, BN, atypical AN

The participants with EDs were, in general, concerned about their teeth. Some feared that they had severe and irreversible tooth damage, and many were overly occupied with oral hygiene procedures. Some of the participants had good experiences in communicating with the dentist and wanted the dentist to address EDs in the clinic. However, participants with less-positive experiences highlighted a need for dentists with specialized knowledge of EDs and communication skills, focusing on an empathic approach from the dentist

Emodi-Perlman [40]

Israel

To compare the prevalence of psychologic, dental, and temporomandibular disorder signs and symptoms between young women suffering from chronic EDs and a control group of age-matched, healthy women, and to evaluate the impact of frequent vomiting on these signs and symptoms among the ED group

Clinical examination and self-administered questionnaires

N = 129

AN, BN, EDNOS

Women with EDs presented higher general muscle sensitivity than healthy women of the same age, as well as higher emotional and psychologic distress. This may suggest a higher susceptibility of women suffering from ED to suffer also from myofascial pain than healthy subjects. Most differences did not reach statistical significance, probably because of the small number in each group and the application of the Bonferroni correction for multiple testing. However, the results clearly indicate some disparity between the 2 groups

Frimenko [30] USA

Assess dental students' ED and interprofessional care (IPC) related educational experiences, perceptions of preparedness for ED-related communication with patients and providers, and attitudes related to an IPC approach to EDs

Paper and web-based survey

N = 596

N/A

3rd and 4th year students felt educated about basic ED related issues (signs, symptoms, systemic effects) but not about ED treatment protocol and referral protocol. Reported asking about physical health and referring but not mental health and rarely referred to mental health provider. Did not feel prepared to communicate with patients and health care providers from other disciplines about mental health

Galindo [31]

USA

To describe the reconstruction of a maxillary anterior segment using immediate implant placement and immediate implant loading techniques, aided by computer- guided implant treatment software and stereolithographic models and surgical templates, in a patient with a history of ED

Case study

N = 1

BN

This clinical report describes rehabilitation using implant- supported FPDs on immediately placed and immediately loaded dental implants, aided by computer-guided implant treatment software, stereolithographic models, and surgical templates, of a partially dentate patient affected by EDs

Giraudeau [32] France

To assess the benefits and feasibility of providing a systematic dental examination via telemedicine for all patients in the ED day hospital

Two phase study: virtual visit and analysis

N = 50

AN, BN

Dental erosion was found in 92% of the patients, and 50% had at least one tooth with a BEWE score of 2 or 3

Hermont [41] Brazil

To compare the occurrence of tooth erosion and dental caries in adolescents with and without risk behavior for EDs

Controlled cross-sectional study

N = 1,203

N/A

Severe risk behavior for EDs was significantly associated with tooth erosion, but not with dental caries

Imai [42]

Japan

To present a case of necrotizing sialometaplasia (NS) accompanied by significant dental erosion of the maxillary teeth of the palatal surfaces owing to chronic self-induced vomiting

Case study

N = 1

N/A

Temporary worsening of binging-purging before the development of NS would likely have led to an increase in traumatic stress and chemical exposure of the palate. Iron deficiency hypochromic anemia could compromise the steady supply of oxygen to the palate locally affected by frequent abnormal eating behaviors. These systemic and local factors might trigger irreversible ischemic changes in the palatal salivary gland tissues for a short time

Johansson [43] Sweden

To compare the oral health status of patients with EDs, with sex- and age-matched controls, with a view to identify self-reported and clinical parameters that might alert the dental healthcare professional to the possibility of EDs

Matched case–control,

questionnaire and dental exam

N = 108

AN, BN, EDNOS

Self-reported presence of dental problems was significantly more common among ED patients compared with controls, and the presence of oral problems on a daily basis was reported by 13% of ED patients compared with only 2% of the controls. The reporting of symptoms on a weekly or daily basis was about two- to three-fold higher in ED patients than in controls

Johansson [33] Norway

To investigate knowledge, attitudes and clinical experience about patients with EDs among Norwegian dentists

Questionnaire sent via mail

N = 1726

N/A

The dentists in this study reported limited clinical experience and insufficient knowledge regarding EDs. There is therefore a need to increase both undergraduate and continuing education in this field

Johansson [59] Sweden

To investigate diet, oral hygiene habits and awareness of possible negative factors for oral health, as well as utilization of dental care in ED patients during periods when self-perceived ED status was "relatively good" vs. "relatively bad”

Case–control

N = 108

AN, BN, EDNOS

The conclusions drawn from this study are that ED patients presents a number of dietary and other types of behavior that are potentially harmful for their general and oral health. For a more accurate detection of these activities, it is important that the patient report on the behaviors both when she/he is in a relatively good as well as being in a more active disease state

Johansson [58] Sweden

To investigate the behavior in ED patients with self-induced vomiting in relation to binge eating, oral health, and dental care

Cross-sectional questionnaire

N = 17

AN, BN, EDNOS

Variation in frequency and duration of episodes of self-induced vomiting indicate that the consequences for oral health will vary and be affected by the specific compensatory behavior executed in patients suffering from an ED. The dental team should be made aware of the likely detrimental effects of binge eating and vomiting on oral health and the large variations of behavior and the cyclical nature of the disease

Lee [34]

Korea

To present case studies that describe the prolonged food restriction of two girls due to the wearing of dental braces in which pathological eating behaviors and serious medical conditions emerged

Case study

N = 2

ARFID, AN

Pathological eating problems may occur in association with orthodontic treatment during adolescence. To prevent serious eating problems that are related to fatal physical conditions, a collaborative assessment between the orthodontist, the patient, the family, and a psychiatrist about the earliest signs of EDs is required

Lifante-Oliva [44] Spain

To study oral complications in females with EDs

Descriptive study

N = 17

ED diagnoses in DSM IV

A significant alteration in oral tissue occurs; this has an adverse impact on oral health, producing an accumulation of local irritants which favor the appearance of oral diseases

Lourenço [45] Portugal

To evaluate the oral health status and orofacial problems in a group of outpatients with EDs

Case–control, questionnaire and dental exam

N = 33

AN, BN

Outpatients with EDs were found to present a higher incidence of oral-related complications and an inferior oral health status, compared to gender- and age-matched controls

Lundgren [46] Denmark

To determine if nocturnal eating is related to tooth loss in a large, epidemiologic sample

Longitudinal, case–control design

N = 2217

NES

The study findings show that nocturnal eating does have oral health implications, supporting previous findings that nocturnal eating, but not evening hyperphagia, is associated with tooth loss, periodontal disease and active tooth decay

Otsu [47]

Japan

To investigate the relationship between the severity of dental erosion and the vomiting behavior and regular dietary habits of patients with EDs

Oral assessment for dental erosion, standardized interview

N = 71

AN, BN, EDNOS

While self-induced vomiting is the main cause of dental erosion in ED patients, the erosion severity may be affected by behavior when inducing vomiting or by routine consumption of certain foods and beverages. Addressing these factors may help prevent severe dental erosion in patients who chronically induce vomiting

Pallier [48]

France

To evaluate dental and periodontal health in anorexia nervosa and bulimia nervosa patients

Case–control full-mouth exam and review of oral hygiene behaviors

N = 140

AN, BN, EDNOS

The study found a significantly different oral disease profile among patients as a function of ED diagnosis type. AN patients presented worse periodontal conditions with higher dental plaque accumulation, gingival inflammation and clinical attachment loss than BN patients. AN patients also reported brushing their teeth more frequently than BN patients (p < 0.01). The findings suggest an adaptation to the prevention of oral diseases according to the ED diagnosis type

Paszynska [50] Poland

To evaluate stimulated and resting salivary flow rate and the activity of the following enzymes in both types of saliva: amylase, aspartate amino transferase (AST), alanine amino transferase (ALT), collagenase, lysozyme, peroxidase, serine and acidic proteases, and trypsin in persons with AN and to compare them with those of healthy controls

Case–control observational

N = 66

AN

Reduced salivary flow might be one indicator of anorexia. Despite starvation and anorexia development, salivary key enzymes show physiological activity. This indicates a partial adaptation of the organism to severe conditions during malnutrition

Paszynska [49] Poland

To establish the oral status regarding caries incidence, tooth wear, gingival inflammation, and oral hygiene levels among severely ill adolescent inpatients diagnosed with AN

Case–control cross‐sectional survey, clinical examination of dental wear

N = 220

AN

Study findings indicate impaired dental and gingival conditions in young people with anorexia. Considering AN’s potential role in oral health, it is essential to monitor dental treatment needs and oral hygiene levels in their present status to prevent forward complications in the future

Rangé [51]

France

To design a questionnaire to identify risk factors and symptoms of oral diseases and to test its reliability as a self-report form among people with AN

Self-report questionnaire, face-to-face repeat questionnaire administered by dentist

N = 69

AN

The study authors developed and tested a questionnaire that identifies risk factors and symptoms of oral diseases in anorexia nervosa. The 26-item form of the questionnaire (long version) is moderately reliable as a self-reported form. A short version of the questionnaire, including the 10 most reliable items, is recommended for oral risk assessment in patients with anorexia nervosa. The clinical value of the self-administered questionnaire remains to be evaluated

Sales-Peres [52]

Brazil

To evaluate the prevalence, distribution, and associated factors of dental wear among patients with EDs

Case–control

N = 60

AN, BN

Dental wear was similar for both groups; the experimental group presented more moderate wear in molars. The etiological factors of tooth wear related with dental wear were biting objects and pain in temporomandibular joints

Sharifian [60] Finland

To evaluate the associations between dental fear and EDs and BMI, with respect to age, gender, educational, sector, attitude to food, and mental well-being among a representative sample of Finnish university students

Cross-sectional secondary analysis of data from University Student Health Survey

N = 3090

No diagnosis, AN, BN, Other

Among the Finnish university students BMI in males and problems of mental well-being in females were positively associated with high dental fear. The results of this study support possible common vulnerability factors that dental fear and other psychological disorders may share

Shaughnessy [53] USA

To evaluate the dental and periodontal health of adolescents and young women with restrictive anorexia nervosa, and the relationship between bone mineral density assessed by dual energy X-ray absorptiometry (DXA) and dental radiographs

DXA bone mineral density measurements,

comprehensive dental examination

N = 23

AN

Despite subnormal DXA measurements in most patients, essentially all adolescents had a normal dental examination. Dental providers should be cognizant of the fact that many patients with EDs may not display the “classic” findings reported in the literature

Sirin [61]

Turkey

To evaluate the levels of dental fear and anxiety in women with EDs scheduled for oral surgery

Case–Control

N = 562

AN, BN, EDNOS

The findings indicate that the ED group had greater levels of dental anxiety and fear than the non-ED dental patients and randomly selected individuals from a nonclinical environment. In addition, significant differences were found between the AN subtypes and the presence or absence of purging behavior

Strużycka Poland [55]

To investigate the prevalence of erosive lesions and related risk factors in the population of 18-year-old young adults in Poland

Cross-sectional clinical assessment of dentition, questionnaire

N = 1869

N/A

In this study, 1.4% reported EDs and prevalence of erosion in anterior region significantly associated with EDs. Roughly half of those who had EDs had varying intensity of erosion type damage to the teeth

Turhani [35] Austria

To address complications and complex management of an active bulimic patient treated with dental implants and elucidate partial failures resulting in mandibular fracture

Case study

N = 1

BN

Dental implant in osteopenic bone predisposes atrophic mandibles for infection and subsequent fracture. Risk/benefit ratio of endosseous implants is not favorable long term, thus people with EDs need to be diligently selected and fully informed of the hazards underlying this type of rehab

Willumsen [62] Norway

To investigate the prevalence of dental fear, dental attendance, reports of dental erosion, and frequency of informing dentists about eating disorders in women with EDs

Questionnaire via mail

N = 371

AN, BN, BED

The survey supports the hypothesis that women with EDs have higher levels of dental fear than women in the general population. The present study further indicates that dental fear is a risk factor for poor dental health in ED patients

Ximenes [54] Brazil

To examine the prevalence of oral alterations related to EDs and associated factors

Cross-sectional self-report questionnaires, dental examination

N = 650

N/A

Significant associations were observed in mucositis, cheilitis, hypertrophy of salivary glands, and dental erosions. The prevalence of adolescents at risk for EDs was of 33.1%, according to EAT-26 and 1.7% (high scores) and 36.5% (medium scores) in BITE. All these factors showed significant relation to EDs